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APPLICATION FOR PERMIT C` SAN JOAQUIN LOCAL HEALTH DISTRICT ,o4AG�►'ti . 1601 E. HAZEL T ON AVE., STOCKTON, CA L Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pgz (Complete in Triplicate) i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is + made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ILY Job Address r I � A/� // ,° City �� ` t Size k�(f PM -SQ N'5 G tj Address 4 Phone r 5' Owner's Name} ,'`` Contractor's Name ► Z.�M License No. Phone-74"� _.P ,3 C` TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑" PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP..LINE Z.:3`L _.. . _� FOUNDATION �_AGRlCULTURE..W, ELLa .OTHER WELL__ PITS/SUMPS __*.i� ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial open Bottom I ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing F E}-B'omestic/Private ❑ Gravel Pack 1 ❑ Tracy Type of Casing I� 5pecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal is Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by �3�? Repair Work Done C1 Type of Pump H.P. State Work Done ._..I Well Destruction ❑ Well Diameter L Sealing Material (top 501 QQ Depth . (ed Filler Material (Below,501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is U f I available within 200 feet.) t � x Installation Will serve: Residence_ Commercial� Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _y Water table depth * r' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _V"w Distance'to nearest: Well Foundation Property Line"" ! LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS -•-�❑—Distance-to-nearest: -Well �F,oundation--�= roperty_Line '^mm --m= ,,: t DISPOSAL PONDS .❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. e Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this-permit is issued, I shall not : employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. p Signed X ✓-�!�._ Title: Date !. Z ;( FOR DEPA TMENT USE ONLY Applgon AcaeptedA by" ' 1 Date rZ /Area t'_ Pit o # nspection by,, Date Final Inspection by ate 4 s� Additional Comments: - c ❑ Stk -466-6781 :V ❑_Ltidi ❑ Man ca 623-7104 ❑ Tracy 635-6385 Applicant- Return copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 59 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO �+ +EH 1324(REV.10/831 EH 14-28 f